Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And joining me today is Dr. Mahathi Indaram. She's a cardiologist and an AHN Cardiovascular Institute physician. She's here today to highlight cardio OB, including hypertensive disorders of pregnancy and preconception risk counseling.

Dr. Indaram, thank you so much for joining us today. I'd like you to start by telling us about maternal mortality. Has the rate of pregnancy-related deaths in the United States been rising? I mean, I know that the reasons, as we think of this, are very complex. But can you tell us a little bit about the trend you've been seeing?

Mahathi Indaram, MD: Hi, Melanie. Thank you so much for having me on this podcast. Yes, absolutely. So, maternal mortality rates have indeed been increasing across the world, but more so in the United States amongst all of the industrialized nations right now. Staggeringly, the statistics have consistently shown us over the last decade that the United States is ranking as number one in terms of maternal mortality.

Amongst the reasons for maternal mortality, actually, heart disease is accounting for the highest cause of maternal mortality in the country as well. Almost close to 20% of maternal deaths are related to heart disease. And amongst heart disease, it is hypertensive disorders of pregnancy, like you mentioned.

Melanie Cole, MS: Well, it is certainly a burgeoning field as we've seen cardio-oncology, and we're learning more in medicine about the effects of the cardiovascular system, the effects that when other systems are working, whether it's pregnancy or anything now. So to me, this is so interesting. Can you tell us a little bit about your field itself? What service lines are under the umbrella of cardio OB? Help us to understand the current and evolving spectrum of cardio-obstetrics.

Mahathi Indaram, MD: Absolutely. So, cardio-obstetrics is a growing subspecialty within cardiology that's essentially focused on prenatal, antenatal, as well as postpartum care of women with heart disease. As we know, during pregnancy, there's so many physiological changes to the woman's body and the heart is working extra hard to pump blood to both the mother and the baby. And so, this additional stress has been shown to unmask risks to heart health that the woman may have already had, but just didn't have a chance to manifest up until that pregnancy.

The stress can also cause new problems to emerge, such as hypertension, diabetes, to name a few. And these can honestly occur anytime during pregnancy, in labor, or in the postpartum period, and sometimes even decades after the pregnancy. So, the field of cardio-obstetrics is almost the need of the hour, because there needs to be this much needed focus on the growth and awareness of the field, like I said, across the country, as well as the world just given the rising rates of maternal mortality.

Melanie Cole, MS: What are the most prevalent hypertensive disorders that you see in your practice?

Mahathi Indaram, MD: The most common is of course what we call gestational hypertension, which means a woman develops high blood pressure during pregnancy. There is a cohort of patients that have what we call chronic hypertension, which means that they may have had hypertension even before pregnancy and that continues during pregnancy.

The more severe forms of hypertension in pregnancy are conditions called preeclampsia and eclampsia. These are very high risk conditions that predispose a woman to having what we call adverse pregnancy outcomes, such as heart failure, diabetes, the baby having growth restriction or being small for its gestational age. And therefore, it is imperative to identify risk factors for these hypertensive disorders, diagnose them appropriately, and manage them effectively at the earliest.

Melanie Cole, MS: Well, then give us an overview, if you would, Dr. Indaram, of the AHN Cardio OB Program. Speak a little bit about the multidisciplinary approach, your team, and what you're doing for patients for other providers.

Mahathi Indaram, MD: Absolutely. So, we have a dedicated cardio-obstetrics program. Our clinic is located at the West Penn Hospital in the city of Pittsburgh, which is one of our sister hospitals with Allegheny General Hospital. We are a team of about five, six cardiologists, and we have a multidisciplinary approach both with general obstetrics as well as Maternal-Fetal Medicine to identify patients who are at risk or who have known heart disease, and we follow them through pregnancy as well as in the postpartum period.

Melanie Cole, MS: What symptoms outside the norm should cardiologists and even obstetricians understand as far as the significant hemodynamic changes that occur during pregnancy, labor, and delivery? What's important as far as focused intervention? Let them know what they should be looking for.

Mahathi Indaram, MD: That's a great question. In terms of what symptoms specifically, as you know, there can be a myriad of presentations for various heart disease conditions across pregnancy. This is for both the woman herself as well as the physicians to identify in terms of any new changes with regards to the exercise capacity or what we call the functional capacity of the patient, if she was previously able to do activities A, B, and C. But during pregnancy or in the postpartum period, those have become difficult in of being limited by excessive shortness of breath or chest discomfort, palpitations, or anything else that the woman or the physician may have noticed in terms of examination, which means excessive body swelling, facial swelling, a drop in how much urine they're able to produce. So, I would say anything that is different from the usual or what we expect to be within the normal range of a pregnancy should be alerted as something that could be high risk and should probably be evaluated as well.

Along with that, it's not just the presentation in terms of symptoms, it's also identifying risk factors. So, if a woman is aware of her own risk factors, as well as her family history, even prior to conception, that is the most ideal. But even if she becomes aware of risk factors during pregnancy, then to promptly discuss that with her doctor at an appropriate time would really help in terms of stratifying her risk much sooner, and then us following along much closely with her during her pregnancy.

Melanie Cole, MS: Well, that leads us very well into the next question. And as you have such a comprehensive approach in the program for high risk pregnancies, tell us about the preconception risk counseling for patients diagnosed with heart issues. What's involved in that counseling and how do patients get involved? How do physicians refer to this program?

Mahathi Indaram, MD: So, like I said, women should be proactive prior to conception ideally to identify any risk factors that they themselves may have or close family members that may carry these risk factors and promptly discuss these with their PCP or their obstetrician. Some of the risk factors that I will highlight, since I brought this up, is essentially an elevated BMI or obesity, which is one of the leading risk factors for hypertensive disorders of pregnancy. Others such as smoking, substance use, race across the United States where African American women have been shown to be at higher risk for pregnancy-related conditions, socioeconomic disparities if they have poor access to healthcare as well. These are some of the common risk factors.

So if identified as high risk for any cardiac conditions, or if they carry any prior diagnosis from their childhood such as congenital heart disease, valvular heart disease, then they should absolutely be referred to both Maternal-Fetal Medicine as well as us cardiologists to further stratify their risk, discuss if pregnancy is even recommended depending on what conditions they may have, and then to ensure close monitoring during pregnancy and postpartum periods.

So at the AHN cardio-obstetrics division, essentially, we encourage the obstetricians that we work with, as well as the Maternal-Fetal Medicine Department to identify these women that they routinely see in their clinic, as well as the primary care physicians, if they come across patients that have any of these conditions that I mentioned and then refer them to us either before pregnancy ideally again, or as soon as they conceive so that we can go over their checklist and make sure that they have everything tied up before they proceed with pregnancy.

Melanie Cole, MS: Such an interesting episode. Doctor, thank you so much for joining us. Before we wrap up, do you have any final thoughts you'd like to leave other providers with? The key takeaways about the AHN Cardio OB program.

Mahathi Indaram, MD: Yes, absolutely. So, the need of the hour is increased awareness about these conditions related to pregnancy, acknowledging that maternal mortality is on the rise across the world. So, any physician that comes across patients, whether in their primary care clinic, OB, like I said, or any other department who they think may be suitable for further evaluation by cardiology, either during, before, or even after pregnancy, please refer them to us. And similarly, also counsel risk within your own clinics. And to patients who are seeking healthcare, to women who are seeking healthcare, like I said, be proactive in terms of adhering to a heart-healthy diet, exercising regularly, avoiding any substance abuse, and then seeking appropriate counseling at the right time.

Melanie Cole, MS: Thank you so much, Dr. Indaram, for joining us today and sharing your expertise with us. And to learn more or to refer a patient, please call 844-MD-REFER or visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network. Please remember to subscribe, rate, and review this podcast and all the other AHN MedTalks podcasts.